Receive Optimum Payment When Billing for Starred Procedures
Published on Thu Jun 01, 2000
Billing for starred CPT surgical codes is subject to a set of rules different from non-starred codes. Knowing these rules as they apply to ob/gyn procedures can save coders headaches and costly claims denials. For the purpose of illustration, endometrial biopsy is used as the coding example, with the central question being whether a practice can bill for a starred procedure and an evaluation and management (E/M) office visit at the same time.
An endometrial biopsy (58100*) is a starred surgical procedure. According to CPT 2000, When a star (*) follows a surgical procedure code number, the following rules apply:
1. The service as listed includes the surgical procedure only. Associated pre- and postoperative services are not included in the service as listed.
2. Preoperative services are considered as one of the following:
When the starred (*) procedure is carried out at the time of an initial visit (new patient) and this procedure constitutes the major service at that visit, procedure number 99025 is listed in lieu of the usual initial visit as an additional service.
When the starred (*) procedure is carried out at the time of an initial or established patient visit involving significant identifiable services, the appropriate visit is listed with the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)appended in addition to the starred (*) procedure and its follow-up care.
When the starred (*) procedure requires hospitalization, an appropriate hospital visit is listed in addition to the starred (*) procedure and its follow-up care.
3. All postoperative care is added on a service-by-service basis.
4. Complications are added on a service-by-service basis.
Cynthia DeVries, RN, BSN, CPC, coordinator of coding and reimbursement for Lee Physician Group, a 140-physician multispecialty group practice that includes 25 ob/gyn providers in Fort Myers, Fla., helps place these rules in a real-life scenario.
Scenario: An established patient presents to her gynecologist with postmenopausal bleeding. The physician takes an appropriate history and examines the patient. The doctor then makes a medical decision to perform an endometrial biopsy at that visit to rule out uterine cancer.
Coding: In this case, you would bill both an office visit for the preoperative evaluation (99212-99215, office or other outpatient visit for the evaluation and management of an established patient), depending on what the physician documented, and the procedure (58100, endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure]), appending the -25 modifier to the office visit.
What CPT doesnt tell you, says DeVries, is the key to getting paid for both services is the use of two different diagnoses. In the real world, if you dont use two different diagnoses, most [...]
